Veterans Rebuilding Life®

INTERVIEW REGISTRATION FORM

NO EXPERIENCE NECESSARY | CERTIFIED ON–JOB TRAINING

Register to Schedule an Interview + Honorable Military Discharge Required

ACCOUNT INFORMATION

LAST

FIRST

M.I.

DATE OF BIRTH

ADDRESS

UNIT #

CITY

STATE

ZIP

PHONE

EMAIL

U.S. CITIZEN?

YESNO

AUTHORIZED TO WORK IN THE U.S.?

YESNO

CURRENTLY SERVING IN THE MILITARY?

YESActiveReservistNO

IF PRIOR SERVICE - WHAT IS YOUR FINAL DISCHARGE?

HonorableGeneralMedicalOther-Than-HonorableDishonorableNot Applicable

MILITARY + CIVILIAN EXPERIENCE

FINAL RANK + POSITION HELD (MOS | AFSC | NEC)

MILITARY TRAINING COMPLETED

SECURITY CLEARANCE? YESClassifiedSecretTop-SecretNot Applicable

CIVILIAN TRADE SCHOOLS COMPLETED

From

To

RECEIVED CERTIFICATION?

YESNO

TITLE OF CERTIFICATION RECEIVED

ATTENDED COLLEGE?

YESNO

INSTITUTION

From

To

GRADUATED?

YESNO

DEGREE RECEIVED

AREAS OF INTEREST

CURRENTLY EMPLOYED?

YESNO

IF YES:

Full TimePart Time

EMPLOYER

POSITION

EMPLOYMENT DATES

From:

To:

CHECK (3) AREAS OF INTEREST

FT/PT Employment

VA Benefit Registration

Veteran Legal Services

Professional Development

Vet 2 Vet Mentorship

Volunteer Opportunities

Accredited Internships

Community Service Hours


ATTACH COPY OF FINAL DD214*

Accepted File Formats: PDF | Word | Jpeg | 5MB or Less

*Form will not submit without DD214 attachment.
DD214 required as evidence of honorable discharge from service: